Ebstein’s anomaly accounts for 0.3% to 0.7% of all cases of congenital heart
disease. The condition is characterized by abnormal tricuspid valve and right
ventricle with apical displacement of tricuspid valve leading to atrialization of
right ventricle. There have been case reports of patients surviving up to ninth
decade. It is unusual for these patients to be asymptomatic in adulthood for long
duration. We describe a patient with Ebstein’s anomaly in the ninth decade with
coronary artery disease.

Introduction

Tuberculosis is seen in every part of the body, but sternoclavicular joint
tuberculosis is rare. The sternoclavicular joint (SCJ) is a saddle type of synovial
joint and it accounts for only 0.5 - 1% of all cases of peripheral tuberculous arthritis
and is more often infected by pyogenic organisms than by the tubercle bacillus.
The pathogenesis of sternoclavicular joint infection is not fully understood but
appears to be haematogenous caused by infected scalene lymph node or directly
from reactivated apical pulmonary focus.

Discussion

We report three cases of
sternoclavicular joint
tuberculosis, in a 49-years-old man (1st)
and a 45-years-old woman (2nd), both
were hypertensive and diabetic and
one 36 years old female (3rd) without
risk factors. Swelling of the SCJ, low
grade febrile illness and loss of weight
were the presenting manifestation.
In first case left SCJ was affected
and in last two cases right SCJ were
affected. Laboratory tests indicated
inflammation in all three of the patients.
The intradermal tuberculin test were
strongly positive in all three patients,
whereas smears and cultures of sputum and urine samples were negative for the
tubercle bacillus.Serologic tests for the
human immunodeficiency virus were
negative. Contrast enhanced computed
tomography (CECT) of thorax showed
inflammatory lesion involving left SCJ
with extension to mediastinum in 1st
case. In 2nd case it showed cold abscess
of right SCJ and in 3rd case necrotic soft
tissue swelling of right SCJ. FNAC of
a specimen confirmed the diagnosis in
2nd case (Figure 1). The outcome was
favorable after treatment with antitubercular
drug for nine months in first
two cases. Third case still undergoing
treatment. 3rd case after discharge
developed severe backache for which
MRI thoracolumbar spine was done which showed as Pott’s spine at D6-
D8 level.So her revised diagnosis was
disseminated Koch’s (Dorsal spine and
right SCJ).

Tuberculosis of the sternoclavicular
joint is rare and can raise diagnostic
problems. The diagnosis should be
considered in every patient with
arthritis in a sternoclavicular joint
or unexplained pain in a shoulder.
Complications include migration
of tuberculous abscesses to the
mediastinum and compression or
erosion of the large blood vessels at the
base of the neck.

Demonstration of acid-fast bacilli,
which is the gold standard for
diagnosis, is extremely rare in these
lesions. Diagnosis is usually based
on demonstration of granulomas on
histopathology.

Conclusion

Despite the availability of advanced
diagnostic facilities , TB of the
sternoclavicular joint often raises
diagnostic problems. It invariably
lead to a delay in treatment which
may raise the incidence of morbidity
and mortality. So early diagnosis is
essential for a good outcome. A high
index of suspicion is mandatory.
Poor response to antibiotic therapy
leads to suspicion of underlying TB
and relevant investigations should be
carried out.